A comparison of Nineteenth-century and Current Attitudes to Female Sexuality

John Studd

Abstract

The nineteenth-century medical attitude to normal female sexuality
was cruel, with gynaecologists and psychiatrists leading the way designing
operations for the cure of the serious contemporary disorders of masturbation
and nymphomania. The gynaecologist, Isaac Baker Brown (1811-1873), and
the distinguished endocrinologist, Charles Brown-Séquard (1817-1894)
advocated clitoridectomy to prevent the progression to masturbatory melancholia,
paralysis, blindness and even death. Even after the public disgrace of
Baker Brown in 1866-7, the operation remained respectable and widely
used in other parts of Europe. This medical contempt for normal female
sexual development was reflected in public and literary attitudes. Or
perhaps it led and encouraged public opinion. There is virtually
no novel or opera in the last half of the 19th century where the heroine
with “a past” survives to the end. H G Well’s Ann
Veronica and Richard Strauss’s Der Rosenkavalier,
both of which appeared in 1909, break the mould and are important milestones.
In the last 50 years new research into the sociology, psychology and
physiology of sexuality has provided an understanding of decreased libido
and inadequate sexual response in the form of Female Sexual Disorder
(FSD) or Hypoactive Sexual Desire Disorder (HSDD). This is now regarded
as a disorder worthy of treatment, either by various forms of counselling
or by the use of hormones, particularly estrogens and testosterone.

Introduction

In Medieval times people feared three things: the devil;
Jews; and women. Female sexuality was a particular source of anxiety
for men, an anxiety that continued until the beginning of the twentieth
century. Wilmot in 1775 translated from the French the book “Nymphomania,
or the Furor Uterinus, clearly and methodically explaining the different
causes of that horrible distemper” (1) which outlined the dangers
to women and society from this serious medical disease. Details of
female anatomy and function seem to be surprisingly well informed for
the period, but it is the condemnation of a normal robust sexuality which
seems eccentric to us today. We are told that female sexuality
is a serpent that is secretly guided into the heart. Goethe, at about
the same time, writing about syphilis, uses similar imagery, demonising
the disease as a beast and warning of “a serpent which lurks in
the loveliest of gardens and strikes us at our pleasures”. The
word “garden”, as in the title of Sir Richard Burton’s
translation of the Arabic erotic work, The Perfumed
Garden (1886), was
a contemporary euphemism for vulva.

Hysteria

In the last half of the nineteenth century, the female disorders
of nymphomania, masturbation, moral insanity, hysteria and neurasthenia
were universally believed to be a serious threat to health and life and
were considered to be the result of reading inappropriate novels or playing
romantic music. This was also the case with what was called “menstrual
madness” and insanity, the history of which is reported elsewhere
(2). They were diseases, which required radical cure. Menstrual madness
was dealt with by laparotomy and bilateral “normal ovariotomy” but
Charcot, with his public demonstrations of hysteria in women in the 1870s,
emphasized his belief that most mental disease in women resulted from
abnormalities or excitation of the female external genitalia (3). These
clinical tutorials were very well attended by scores of men, who
witnessed in pornographic detail the role of the vulva and clitoris in
the causation of hysterical attacks in Charcot’s young and
attractive patients. Charcot’s pupil, Sigmund Freud, who
attended these demonstrations at the La Salpêtrière for
5 months , repeated this fashionable view in his writings and lectures
while also stressing the effect of the mind on gynaecological and mental
disease(4). There is good evidence that even Freud modified his case
histories - excluding the realities of deviant sexuality and sexual
abuse and replacing them with sexual fantasies (5) which would be much
more acceptable to the Viennese upper middle class who were his audience..

Masturbation

There was also the clear belief that masturbation led to
a series of disasters progressing through insomnia, exhaustion, neurasthenia,
epilepsy, moral insanity, insanity, convulsions, melancholia, and paralysis,
to eventual coma and death. Charles Brown-Séquard, the founder
of modern endocrinology, added blindness to this list of penalties. (6)
This clinical entity was known as masturbatory melancholia or masturbatory
paralysis. Even the usually sound Lawson Tait stated in 1889 that
the evils of masturbation had been greatly exaggerated, although he
had seen epidemics of “this vice” in girls’ schools.
If it persisted, the child should be taken into care. (7) The irrepressible
physician Colombat d’Isere who had already shocked his contemporaries
by suggesting that young women should have a tepid bath at least once
a month confirmed the danger of the violent intimacies formed at boarding
schools .The end result of “onanism, that execrable and fatal evil,
soon destroys her beauty, impairs her health , and conducts her almost
always to an early grave”(8)

This horror of female sexuality was also shared and promoted by gynaecologists,
who seemed to put white professional women on a pedestal of virtuous
decency. Charles Meigs, Professor of Gynaecology in Philadelphia,
wrote extensively on the purity of women and the harmful effects of the
speculum on these “dear little ladies fit only for love”.
(8) The suggestion was that “modesty was preferable to diagnosis
and treatment” and the speculum was a “piece of gratuitous
and unprincipled indecency”. Matters became worse when it
was claimed that ladies of rank in France would write notes to their
surgeon requesting him to call at the house and bring his speculum.(9) As
the clitoris seemed to be the cause of this potential moral decline,
the treatment was clear . It had to be removed or destroyed.

Removal of clitoris

Initially, leaches were applied to the vulva and
anus, the clitoris was cauterised and the first known therapeutic function
of x-rays was to irradiate and destroy the clitoris in these women. All
of these assaults on the female genitalia were superseded by the fashion
for clitoridectomy from the 1860s, being supported by Isaac Baker Brown
in London and Charles Brown-Séquard in Paris. These were both
highly distinguished figures who greatly influenced practice.

Isaac Baker Brown

Isaac Baker Brown was by repute a brilliant surgeon who wrote the first
book devoted purely to gynaecological surgery in 1854. (10) When Marion
Sims from New York visited Europe for his extensive private practice,
he always visited Dublin, his favourite city in the British Isles, and
Baker Brown, the best surgeon in the British Isles.(11) Incidentally,
this irritated Lawson Tait of Birmingham, who considered Baker Brown
to be a surgeon of great ability but only the second best surgeon in
Britain.(12) Baker Brown was a gynaecologist at the Samaritan Hospital
London and had his own private clinic, the London Surgical Home, where
he operated on rich upper class women. The wealth of his practice and
the social credentials of his patients were legendary.

He published in 1866 a short 90 page book on the Curability
of Certain Forms of Insanity, Epilepsy, Catalepsy and Hysteria in Females.(12) This
caused one of the biggest medical rows of the century and was perhaps
the most famous publication resulting in professional suicide in the
history of medicine. Before publication, Baker Brown had been held in
high repute, but within a year he was ruined.

Because the clitoris was widely understood to be an important
source of disease, Baker Brown believed that clitoridectomy was a cure
not only for nymphomania and masturbation but also epilepsy, catalepsy,
painful periods, heavy periods, depression, insanity hysteria and dementia. In
his book, he did not use the word masturbation, preferring the term “peripheral
excitement”, the euphemism always used by the experts of on this
subject, including Brown-Séquard. (6)

An example of this usage occurs in a case from Baker Brown: “there
was evidence of peripheral excitement. I performed my usual operation
and the patient made a good recovery. She remained quite well and
became in every respect a good wife”. Baker Brown’s interpretation
of this case is worth noting: “the illness” was her desire
to obtain a divorce under the new divorce act of 1857. On another occasion,
he performed a clitoridectomy on a 20-year-old woman because she
was “disobedient to her mother’s wishes, sent visiting cards
to men she liked and spent much time in serious reading”.

A typical non-sexual indication was in case XVI: “Has never
been strong but 5 years ago had an attack of gastric fever and since
then has suffered constantly from great pain during the menstrual period,
occasionally loses a great deal and passes large clots of blood. During
this time has suffered almost constantly from leucorrhoea, suffers severely
from pain over the region of the left ovary and in the spine. Is
hardly ever free from headaches, is very restless, never sleeps well,
frequent faints, has little or no appetite, all her ills are exaggerated
at the menstrual époque. August 7th usual operation performed
September 1st is menstruating without pain. September 30th is
again menstruating without pain and in normal quantity. Is to be
discharged cured.(12) Readers will note the long period of
hospitalisation in Baker Brown’s private clinic and a very short
duration of follow up before claiming success for his procedure.

His book produced criticism from the Lancet and the British
Medical Journal and unrestrained hostility in the London Times. Within a year
Baker Brown was expelled from the London Obstetric Society after a fierce
debate led by his professional rivals. This meeting was notable for being
fired by commercial jealousy as much as disapproval of his surgery. Baker
Brown’s downfall was complete when he resigned in the same year
from the London Medical Society where he served as President*. He died
in 1873, in penury and suffering from incurable paralysis. The autopsy
was allegedly performed by his professional rival, Lawson Tait (although
no primary source can be found to substantiate this claim). Lawson
Tait pronounced that Baker Brown had the cerebral softening of advanced
neurosyphilis. It is tempting believe that this gifted and pioneering
surgeon, who is now only remembered because of his advocacy of clitoridectomy,
had this aberration later in life because of the behavioural disorder
of cerebral syphilis. Or perhaps the temptation to unfairly stigmatize
a rival even in death was irresistible to Lawson Tait. This is unlikely,
however, as it is clear from a publication twenty years later that Tait
had some respect for “the second best ovariotomist” who,
in his view, did not deserve his disgrace.(13) We are told that although “semi-demented
epileptics were habitual masturbators”, the mistake of Baker Brown
was “jumping over two grave omissions in the syllogism and putting
the cart before the horse, he arrived at the conclusion that the removal
of the clitoris would stop the pernicious habit and therefore cure the
epilepsy”. (13a)

Zambaco

But the practice continued in Europe, supported by influential physicians
and psychiatrists. Zambaco of Paris reported in 1882: “masturbation
and psychological problems in two little girls”, one aged 10 and
her sister, aged 6.(14) He reported that neither corporal punishment
such as whipping or restraint with straps helped, nor did the threat
that excessive masturbation would damage the elder girl’s
health and her reputation. Only cautery without anaesthesia helped. This
was performed by electro-cautery, or more effectively by a red hot iron
from the coals. This was applied to the clitoris, the vulvar orifice
repeatedly, and on one occasion to the buttocks as “punishment”.
He concluded that one should not hesitate to have recourse at a very
early stage to the red hot iron as a cure for clitoral or vaginal masturbation
in little girls. The author enjoyed an illustrious career and became
a commander of the Legion of Honour. The article was cited by Krafft-Ebing,
professor of psychiatry in Vienna, who called it a disgusting story not
because of what Zambaco did but because of what Zambaco saw. (15)

Although Zambaco’s long paper is so shockingly explicit
in its inhumanity and pornographic detail, we should not forget
the unheeded silent suffering that is still occurring today in thousands
of young girls in parts of Africa and the Middle East. We have a long
way to go before female genital mutilation in all its forms is consigned
to history.

Titian/Mark Twain

It is interesting to note how literature followed the
contemporary prudish and censorious views prevalent in medicine - or
perhaps it led the way. Mark Twain, in his A Tramp Abroad (1889),
(16) wrote about the exquisite Titian portrait, The Venus of Urbino.

click to see a larger image

(Fig
1, left) She famously
adorns the Uffizi Gallery, lying naked with her left hand over her pubic
hair. At first sight it may be unclear whether she is being modest or
having fun. But to judge from her fingers, curled into her pubis, and
the look on her beautiful face, she is clearly teasing her lover, the
Duke of Urbino. The erotic nature of this picture has always been clear
to art historians. Mark Twain wrote about “the foulest, the vilest,
the obscenest picture the world possesses. It isn’t that she is
naked and stretched out on the bed – no, it is the position of
her hand. I saw a young girl stealing furtive glances at her, I saw young
men gazing long and absorbedly at her, I saw aged infirm men hanging
upon her charms with a pathetic interest. How I should like to describe
her… yet
the world is willing to let its sons and its daughters and itself look
at Titian’s beast but won’t stand a description of it in
words”. Of course Mark Twain loved the picture. His protest was
about the limitation imposed on the written word by censorship from publishers
and the powerful lending libraries.

Literary context

In nineteenth-century European literature there is a
hardly an example of a female character who has what was called “a
past”,
or who has had an adulterous relationship, who survives to the end of
the novel, regardless of the country of origin. The fate of the fallen
woman was suicide, murder, or deportation to Australia. It would
be reassuring if redemption was one of the options, but no examples come
to mind. David Copperfield’s childhood sweetheart, little
Emily, is deported to Australia as the result of having been seduced
by David’s best friend. In Oliver Twist, the prostitute
Nancy dies horribly at the hands of her lover, Bill Sykes, and in another
Dickens novel, Bleak House, Lady Deadlock - who had a lover and
an illegitimate child years before marrying her husband - dies after
a 12 hour walk through the night in the snow. Tolstoy’s Anna Karenina
expiates her sins by jumping under a train. And Flaubert’s Emma
Bovary dies of arsenic poisoning, as described in horrific detail over
many pages. It is said that Tolstoy and Flaubert loved their heroines
but were forced by public expectation to end their characters’ lives
by such shocking and ghastly deaths.

Operatic context

Similarly, in nineteenth century opera all the heroines
with a sexual past die. The most famous and perhaps the first musical
description of sexual intercourse occurs in Act II of Tristan
und Isolde, which leaves
nothing to the imagination. But in this opera, both lovers have to die
in the end - like most of Wagner’s wonderful heroines. Wagner the
man allowed himself much sexual license – a freedom he does not
allow his Brunnhilde, Seiglinde, Kundry and even the Dutchman’s
poor Senta, who only makes such a promise. All these heroines
succumb to the contemporary need for punishment of female sexuality.
The virtuous women like Eva, Elizabeth, Gutrune and the Rhinemaidens
live another day. Most of Verdi’s heroines with a
sexual history - Aida, Violetta and Gilda - die; although mezzos, who
are usually more sinister characters, seem to have a better survival
rate than sopranos. Similarly, all Puccini’s heroines with a sexual
past - such as Mimi and Tosca - succumb before the final curtain. In
contrast, Turandot’s virginity guarantees her survival in spite
of her appalling murderous behaviour.

Richard Strauss’s Salome (1905) - using Oscar Wilde’s
play as libretto - could have been a turning point, as the play is unashamedly
sexual. It was banned in the UK until 1908 and was banned in New
York for 27 years after a mere 2 performances. However, the libidinous
Salome also meets her end in the final minutes of the opera. Eighteenth-century
composers were more forgiving. Poppea, one of the most promiscuous women
in opera, survived to marry the emperor in both the Handel and Monteverdi
account. Agrappina and Calisto thrive, and Don Giovanni’s seduced
women survive to witness his descent into hell.

Contemporary art

The prudery and hypocrisy of the last half of the 19th
century was challenged by artists. Manet’s Dejeuner
sur l’Herbe (Fig 2 below),
refused for exhibition in1863, is now recognised as a masterpiece. Courbet’s
graphically gynaecological L’Origine du Monde (Fig 3 below)
in the Musee d’Orsay, and the erotic lesbianism of The
Sleepers (Fig 4 below),
were both painted in 1866 and probably appears less shocking in these
enlightened days than in the artistic world of contemporary Paris. Even
the half naked Salome of Lovis Corinth (1900) (Fig 5 below) is
now allowed to be given a sexual interpretation - inspecting the head
of her would-be lover in anything but a biblical pose.

click to see larger images

Fig 2

Fig 3

Fig 4

Fig 5

Early 20th Century

What happened at the end of the 19th century? When
did literature, society and indeed medicine catch up with the artists
and accept that sex was fun and that fallen women did not have to end
up dead or transported? And in the real world, when did enthusiastic
female sexuality cease to be a target for demented doctors? Literary
colleagues have informed me that the novel Ann Veronica (1909)
, by H G Wells, was such a turning point. Wells was a feminist as well
as a futurist, and his headstrong heroine leaves home after her father
forbids her, to study science, lives by herself, has boyfriends, has
intercourse for the first time after the opera (Tristan und Isolde,
as it happens), and continues a life of politics and feminism amongst
the Suffragettes.

The turning point in music must be Der Rosenkavalier, first produced
in the same year as the publication of Well’s Ann
Veronica, 1909. In
the words of the opera critic, William Mann, the prelude is “an
unrestrained and highly suggestive musical description of the act of
love”. Decades later, with our new knowledge of physiology,
we are able to follow Masters and Johnson’s four phases of human
sexual response in the music. The quotes are not mine or invented but
belong to Mann from his classic reference work, The
Operas of Richard Strauss. (17)

Excitation “nobody who understands the language of music can
misunderstand the meaning of the initial rising horn call”,

Resolution, “dawn and birdsong and music of loving contentment
and a theme of aching passion”.

Then the curtain is raised to reveal a scene with two scantily clad women
in bed. There is no ambiguity here. The young boy Octavian, mezzo soprano,
and the older, but very beautiful, Field Marshall’s wife, Marie Therese,
the soprano. Sadly, the music tells us that Octavian, in his youthful
inexperience, reaches his climax too soon, with the whole sexual episode in
the Prelude lasting no more than 59 seconds, in what is a clear musical account
of premature ejaculation.

Strauss wrote similar erotic descriptions in Symphony
Domestica and the Prelude to act 3 of Arabella - but nothing to match the prelude
to Der Rosenkavalier. It is hoped that the reader will never again listen
to this piece without an understanding smile on the face and satisfaction
in the soul.

Marie Stopes

In the real world, however, acceptance of the importance of satisfactory
orgasmic sexual intercourse was slow. Marie Stopes’s Married
Love (1918)
(18) has been listed by Bragg (19) as one of the 12 books that “changed
the world”. Written by a female doctor falling back on her
own painful sexual failures before and after her marriage, it movingly
relates the dangers of ignorance, and the no longer forbidden pleasures
that can be achieved with sexual intercourse within marriage. Most publishers
turned down the manuscript but eventually it was accepted by a
small publisher and became an immediate best seller. However it was banned
in America until it was first published in 1931 Marie
Stopes wrote about the “virgin sweetness of women shut in ignorance
and these in the pristine purity of an educated girl of the northern
race”. She accepts that men are often bewildered by causing
pain with intercourse… as he finds restraint and self-control
urged on him by books, he compensates by working hard and arriving home
late in the evening”. She believed that such was the fear of sexuality
that several brides resorted to suicide or insanity rather than accept
the horrors of the first night. She regretted the notion deeply
rooted in society that a woman is lowered by sexual intercourse. Married
Love achieved a realisation in the community that sex was good, but
Stopes deliberately only discussed sexual intercourse within marriage
and in early editions did not speak about contraception, miscarriage
or even achieving an orgasm without her husband. However, she
does seem a little out of date, informing us that even when the woman
is “strongly sexed with a well marked recurrence of desire it is
generally satisfied by fortnightly unions”. She states that
the supreme law for husbands is to remember that each active union must
be tenderly wooed for and won and that no union should ever take place
unless the woman who also desires and it is made physically ready for
it.

Late 20th Century

Kinsey and colleagues in 1953 (20) broke the scientific
silence by publishing the controversial Sexual Behaviour in the Human
Female, which reported
on taboo subjects such as orgasm, masturbation, pre marital sex and infidelity
within marriage. The public reaction ranged from disbelief and disgust
to admiration and gratitude. But at last people were armed with the facts
of female sexuality and the work remains the standard text on the
subject.

Twenty years later Seymour Fisher (21) devoted a whole book to
the female orgasm, discussing the psychology, physiology and fantasy
of the event. In his study of 300 women only 39% clamed to always
or nearly always orgasm during intercourse, with only 20% stating that
they did not need “a final push” for orgasm by manual stimulation.
If given the choice, 64% would chose clitoral stimulation rather than
vaginal. The Victorians would never have believed it. Not to be outdone,
Shere Hite (22), in her extensive use of questionnaires from women, describes
6 basic types of masturbation in women, each sub-divided into 5 variations.
It is unscientific but a fascinating read.

Masters & Johnson’s (23) work on the physiology of Sexual
Intercourse in the Normal Female Social Response was a landmark piece
of research which has helped women, their partners and medical advisers
understand the events of sexual excitement.. They brought discussion
rather than an embarrassed silent dismissal of the subject. The researchers
initially used prostitutes for the laboratory studies of coitus but had
to change to other volunteers as the sex workers were habituated to intercourse
without orgasm.

They were able to show the hyperaemia of the vulva, the enlargement
and erection of the clitoris and the transudation of fluids from the
peri vaginal vasculature during the excitation phase. This was followed
in the plateau stage by dilatation of the upper third of the vagina and
the formation of the orgasmic platform in the outer third of the vagina.
Orgasm consisted of involuntary contractions of the pelvic and uterine
musculature, often accompanied by uncontrolled physical and verbal responses.
Resolution was essentially the reversal of these hyperaemic changes back
to the normal unstimulated state.

Current sexual attitudes

Attitudes to the female orgasm have undergone
a convulsion. The front covers of monthly magazines for women blatantly
advertise “40
ways to orgasm this weekend – How to Achieve an Orgasm Every Time – Would
you dare Hire a Male Escort – How to Effectively Perform Oral Sex,
With or Without a Condom”. We now recognise the problems
of the loss of libido produced in relationships and even have a syndrome
of Female Sexual Dysfunction (FSD). (24) Sexual satisfaction has
now become virtually compulsory with treatments ranging from psychosexual
counselling to hormone therapy with estrogens or androgens.

FSD is a complex issue probably made more complex by investigators who
subdivide it into Hypoactive Sexual Desire Disorder (HSDD), Sexual Arousal
Disorder, Sexual Aversion and many other sub groups. The different
factors which play a part in female sexual response are physiological,
psychological, interpersonal relationships and socio-cultural influences.
These are perhaps expressed more simply as Heart, Head and Hormones. Patients
understand this.

Testosterone for women

Finally, there must be a brief comment on the
21st century to see how attitudes to female sexuality have been modified
with acceptance of the concept of androgen deficiency (25). For about
30 years now, there have been a few eccentrics like Greenblatt (26) and
Studd (27) who gave testosterone to women for various psychosexual and
mood problems. This was in the form of testosterone implants because
that was the only preparation licensed for use in women. The clinical
response has been impressive, but the treatment for loss of libido
did lack scientific confirmation until very recently.

Testosterone is a normal female hormone present in 10 times the level
of oestradiol in young women, but levels begin to decline at the
age of 20 and by the time of the natural menopause there is also a 50%
fall, and a 75% fall after bilateral oophorectomy.(28). The decline in
androgen levels contributes to the decline in sexual desire, arousal
and orgasm and also has effects on general well being, energy, mood,
bone physiology and decreased muscle mass, as well as hot flushes. This
is now regarded as the Female Androgen Deficiency Syndrome (FADS).(25)
It is no surprise that FADS occurs commonly after bilateral salpingo-oophorectomy,
but we do not know its incidence after hysterectomy with ovarian conservation. It
is not rare. Nor is it rare in intact post-menopausal women, peri-menopausal
women or even younger women who have an impaired sexual response.

There are now gels licensed for men which are often used off license
in a smaller dose for women, and at last a testosterone patch has recently
received a license specifically for use in women who have had a hysterectomy
and bilateral salpingo oophorectomy. The studies have demonstrated the
positive effects of transdermal testosterone patch on sexual desire,
sexual activity, orgasm, pleasure, responsiveness and self image with
a corresponding decrease in sexual distress. (29) Although there is a
tendency to equate testosterone therapy with a sexual response measured
by increased sexual episodes, libido and easier orgasms, it is important
to realise that there is a non-sexual component in these benefits. Women
speak of greater self- confidence, greater mental acuity and less depression,
and they even speak about greater efficiency and communication in
their work. They are also aware of increased self worth and state that
they behave like wanted women rather than neglected ones. These
non-sexual components, although important, are more difficult to assess
in trials and therefore, alas, have not been evaluated.

This information does leave the question about who should be treated.
Clearly, nearly all women who have had a bilateral oophorectomy should
have appropriate replacement therapy which should consist of testosterone
as well as the more obvious estrogen. Now that testosterone is available
on license for women, it is hard to justify oophorectomy in pre-menopausal
women without replacement of testosterone (30). Although there
is no license for non-hysterectomised women to receive testosterone,
there is no doubt that good, well experienced doctors will prescribe
testosterone in such women and even in those who are pre-menopausal with
the appropriate symptoms. Prescribing “off-licence” is
controversial, but it happens.

Testosterone treatment is very effective with the potential complications
of acne and hirsutism rare if levels are kept within normal values. After
many years of therapy women often experience a slight enlargement and
increased sensitivity of the clitoris, but they never complain about
it as an adverse effect! They are happy with the change, or perhaps they
wish to avoid the 19th century attack on the clitoris

We have come a long way from Baker Brown’s clitoridectomy as a
cure for a young woman’s normal sexual behaviour, but the revolting
practice of female circumcision remains a commonplace cultural requirement
in many parts of the world. Even the new Western vogue of vulvovaginal
rejuvenation and labial trimming - performed in order to look like an
airbrushed porn star - as advertised in the more disreputable medical
websites, looks backwards to these customs of female genital mutilation.
In general, we still have a great deal to learn, with medical history
teaching us that many of our beliefs today will be regarded as
eccentric at least, or perhaps clearly dangerous, in years to come. We
must never forget that we used to bleed for anaemia

This paper was originally given as a lecture to The London Medical
Society in 2006